LAPORAN PRAKTIKUM FARMASI KLINIS: REVIEW PENDAHULUAN (Analisis Kefarmasian Kasus CAP, COPD, HF)
I. THEORETICAL BASIS
Community-acquired pneumonia is a leading cause of death. Risk
factors include older age and medical comorbidities. Diagnosis is suggested by
a history of cough, dyspnea, pleuritic pain, or acute functional or cognitive
decline, with abnormal vital signs (e.g., fever, tachycardia) and lung
examination findings. Diagnosis should be confirmed by chest radiography or
ultrasonography. Validated prediction scores for pneumonia severity can guide
the decision between outpatient and inpatient therapy. Using procalcitonin as a
biomarker for severe infection may further assist with risk stratification.
Most outpatients with community-acquired pneumonia do not require microbiologic
testing of sputum or blood and can be treated empirically with a macrolide,
doxycycline, or a respiratory fluoroquinolone. Patients requiring
hospitalization should be treated with a fluoroquinolone or a combination of
beta-lactam plus macrolide antibiotics. Patients with severe infection
requiring admission to the intensive care unit require dual antibiotic therapy
including a third-generation cephalosporin plus a macrolide alone or in
combination with a fluoroquinolone. Treatment options for patients with risk
factors for Pseudomonas species include administration of an
antipseudomonal antibiotic and an aminoglycoside, plus azithromycin or a
fluoroquinolone (Kaysin & Viera, 2016).
Chronic Obstructive Pulmonary Disease
(COPD) is a preventable and treatable lung disease. People with COPD must work
harder to breathe, which can lead to shortness of breath and/or feeling tired.
Early in the disease, people with COPD may feel short of breath when they
exercise. As the disease progresses, it can be hard to breathe out (exhale) or
even breathe in (inhale). A person with COPD may have obstructive bronchiolitis
(bron-kee-oh-lite-is), emphysema, or a combination of both conditions. The
amount of each of these conditions differs from person to person. Asthma is
another disease that causes narrowing of the airways, making it hard to breathe
at times, but asthma is not included in the definition of COPD. Some people do
have a mix of both COPD and asthma (Lareau, dkk., 2019).
Heart
failure (HF) is a clinical syndrome caused by structural and functional defects
in myocardium resulting in impairment of ventricular filling or the ejection of
blood. The most common cause for HF is reduced left ventricular myocardial
function; however, dysfunction of the pericardium, myocardium, endocardium,
heart valves or great vessels alone or in combination is also associated with
HF. Some of the major pathogenic mechanisms leading to HF are increased
hemodynamic overload, ischemia-related dysfunction, ventricular remodeling,
excessive neuro-humoral stimulation, abnormal myocyte calcium cycling,
excessive or inadequate proliferation of the extracellular matrix, accelerated
apoptosis and genetic mutations (Inamdar, A.A. &
Inamdar, C.A., 2016).
II.
ALGORITHM THERAPY
a. Community-acquired
Pneumonia Therapy Algorithm
b. Chronic
Obstructive Pulmonary Disease Therapy Algorithm (COPD)
c.
Heart
Failure Therapy Algorithm
d. FARM
Finding |
Assessment |
Resolution and Monitoring |
Patient progress
notes: · GCS= 456: tgl
14-18 · Batuk dahak
(kuning): tgl 14-18 · Sesak nafas: tgl
14-18 · Hematemesis: tgl
17-18 · Melena: tgl
17-18 Clinical signs: · TD Tgl
14/6: 130/70 Tgl
16/6: 130/70 Tgl
17/6: 130/80 Tgl
18/6: 130/80 · HR Tgl
14-18: di atas normal Lab data: · Leukosit= 15.980 · Hematocrit= 35-50% · Ureum/BUN= 1,53 · Kreatinin= 1,49 · pCO2= 51,3 · HCO3= 34,9 |
Community
Acquired Pneumonia (CAP) Cefoperazon · Cephalosporin
class of antibiotics, which are antibiotics for the treatment of
gram-negative bacterial infections (third generation). · This drug works
by inhibiting the formation of bacterial cell walls thereby preventing
bacterial growth. Levofloxacin · Quinolone class
of antibiotics which are broad spectrum antibiotics for the treatment of
gram-negative and gram-positive bacterial infections. ·
This drug works by cause bacterial cell death due to
inhibition and increased concentration of the gyrase and topoisomerase
enzymes. |
· It is
recommended to use levofloxacin because of a broad-spectrum antibiotic. · The dose is correct:
750 mg every 48 hours (i.v.), adjusted for the patient's GFR value of 26.17 · GFR values
must be calculated because it is related to kidney function. The lower the
GFR value means that the kidney condition is getting worse. · For all patients
with kidney disorders, care should be taken to take the dosage of the drug to
be given. · Antibiotics
given (levofloxacin) are in accordance with first line therapy. |
Finding |
Assessment |
Resolution and Monitoring |
Patient progress
notes: · GCS= 456: tgl
14-18 · Batuk dahak
(kuning): tgl 14-18 · Sesak nafas: tgl
14-18 · Hematemesis: tgl
17-18 · Melena: tgl
17-18 Clinical signs: · TD Tgl
14/6: 130/70 Tgl
16/6: 130/70 Tgl
17/6: 130/80 Tgl
18/6: 130/80 · HR Tgl
14-18: di atas normal Lab data: · Leukosit= 15.980 · Hematocrit= 35-50% · Ureum/BUN= 1,53 · Kreatinin= 1,49 · pCO2= 51,3 · HCO3= 34,9 |
Chronic
Obstructive Pulmonary Disease (COPD) Combivent · Contains
Ipratropium Bromide, Salbutamol Sulphate. Salbutamol · Function as a
bronchodilator. · Mechanism of
action for muscle relaxation in the respiratory tract so that it stimulates
adrenergic beta 2 receptors. Ipratropium
bromide · It has a
bronchodilating effect. Pulmicort · Contains
Budesonide. ·
Budesonide is a corticosteroid class of drugs. · Mechanism of Action: Exerts mucolytic action
through its free sulfhydryl group which opens up the disulfide bonds in the
mucoproteins thus lowering mucous viscosity. · Serves to reduce
the viscosity of mucus, so it is expected that mucus can be eliminated. Metil prednisolon · Corticosteroid
drugs, which function to inhibit prostaglandins so it can treat inflammation
of the lungs. |
· This drug is
suitable for the treatment of COPD. · Frequency of
drug use can be increased if needed. · The amount of
puff applied depends on the strength of the active substance. · The dosage is
correct. · The dosage is
correct. · Administration
of high dose methyl prednisolone route i.v. at risk of causing hypotension
and cardiac arrhythmias. · i.v. route dose
conversion being oral by using body weight, with a conversion value of
0.5-1.7 mg/kg/day, so the maximum dose for patients with 52 kg body weight is
26-88.4 mg/kg/day. |
Finding |
Assessment |
Resolution and Monitoring |
Patient progress
notes: · GCS= 456: tgl
14-18 · Batuk dahak
(kuning): tgl 14-18 · Sesak nafas: tgl
14-18 · Hematemesis: tgl
17-18 · Melena: tgl
17-18 Clinical signs: · TD Tgl
14/6: 130/70 Tgl
16/6: 130/70 Tgl
17/6: 130/80 Tgl
18/6: 130/80 · HR Tgl
14-18: di atas normal Lab data: · Leukosit= 15.980 · Hematocrit= 35-50% · Ureum/BUN= 1,53 · Kreatinin= 1,49 · pCO2= 51,3 · HCO3= 34,9 |
Heart Failure
(HF) Captopril ·
Pharmacologic Category:
Angiotensin-Converting
Enzyme (ACE) Inhibitor · Mechanism of Action: Competitive
inhibitor of angiotensin-converting enzyme (ACE); prevents conversion of
angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower
levels of angiotensin II which causes an increase in plasma renin activity
and a reduction in aldosterone secretion. · A persistent,
dry cough in a patient using captopril as medical
treatment, should be considered as an adverse effect. · Mechanism of Action:
Competitive inhibitor of angiotensin-converting enzyme (ACE); prevents
conversion of angiotensin I to angiotensin II, a potent vasoconstrictor;
results in lower levels of angiotensin II which causes an increase in plasma
renin activity and a reduction in aldosterone secretion. · Labeled Indications: Treatment of hypertension,
either alone or in combination with other antihypertensive agents; adjunctive
therapy in treatment of heart failure (HF). Amlodipine · Pharmacologic
Category: Calcium
Channel Blocker. ·
Mechanism of Action: Inhibits calcium ion from entering the slow
channel or select voltage-sensitive areas of vascular smooth muscle and
myocardium during depolarization, producing a relaxation of coronary vascular
smooth muscle and coronary vasodilation; increases myocardial oxygen delivery
in patients with vasospastic angina. Furosemide · Pharmacologic
Category: Loop Diuretic. ·
Labeled Indications: Management of edema associated with congestive
heart failure and hepatic or renal disease; alone or in combination with
antihypertensives in treatment of hypertension. · Mechanism of Action: Inhibits
reabsorption of sodium and chloride in the ascending loop of Henle and distal
renal tubule, interfering with the chloride-binding cotransport system, thus
causing increased excretion of water, sodium, chloride, magnesium, and
calcium. |
· The patient has
a history of COPD, which coughs, so if given captopril it will worsen the
cough disease. · A suggestion is
to stop using captopril, and only lisinopril is given. · Lisinopril dose
given to patients with kidney disorders is appropriate. · Amlodipine selection
is appropriate because it is selective in blood vessels and rarely causes
tachycardia. · The dose of amlodipine
given by p.o. route already right. · The purpose
given furosemide is for fluid retention. · The dose of
furosemide given by i.v. route already right. |
Finding |
Assessment |
Resolution and Monitoring |
Patient progress
notes: · GCS= 456: tgl
14-18 · Batuk dahak
(kuning): tgl 14-18 · Sesak nafas: tgl
14-18 · Hematemesis: tgl
17-18 · Melena: tgl
17-18 Clinical signs: · TD Tgl
14/6: 130/70 Tgl
16/6: 130/70 Tgl
17/6: 130/80 Tgl
18/6: 130/80 · HR Tgl
14-18: di atas normal Lab data: · Leukosit= 15.980 · Hematocrit= 35-50% · Ureum/BUN= 1,53 · Kreatinin= 1,49 · pCO2= 51,3 · HCO3= 34,9 |
Hematemesis and
Melena Sucralfat · Pharmacologic
Category: Gastrointestinal
Agent. ·
Mechanism of Action: Forms a complex by binding with positively
charged proteins in exudates, forming a viscous paste-like, adhesive
substance. This selectively forms a protective coating that acts locally to
protect the gastric lining against peptic acid, pepsin, and bile salts. Lanzoprazole · Pharmacologic
Category: Proton
Pump Inhibitor. ·
Mechanism of Action: Decreases acid secretion in gastric parietal
cells through inhibition of (H+, K+)-ATPase enzyme system, blocking the final
step in gastric acid production. Aspirin · Pharmacologic
Category: Salicylate (NSID). ·
Labeled Indications: Treatment of mild-to-moderate pain, inflammation,
and fever; may be used as prophylaxis of myocardial infarction; prophylaxis
of stroke and/or transient ischemic episodes; management of rheumatoid
arthritis, rheumatic fever, osteoarthritis, and gout (high dose); adjunctive
therapy in revascularization procedures (coronary artery bypass graft [CABG],
percutaneous transluminal coronary angioplasty [PTCA], carotid
endarterectomy), stent implantation. ·
Mechanism of Action: Irreversibly inhibits cyclooxygenase-1 and 2
(COX-1 and 2) enzymes, which result in decreased formation of prostaglandin
precursors; has antiplatelet, antipyretic, analgesic, and anti-inflammatory
properties. Simvastatin · Pharmacologic
Category: Antilipemic
Agent, HMG-CoA Reductase Inhibitor. · Mechanism of Action: Simvastatin
is a methylated derivative of lovastatin that acts by competitively
inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, the
enzyme that catalyzes the rate-limiting step in cholesterol biosynthesis. · Secondary prevention of cardiovascular
events in hypercholesterolemic patients with established coronary heart
disease (CHD) or at high risk for CHD: To reduce cardiovascular morbidity
(myocardial infarction, coronary revascularization procedures) and mortality;
to reduce the risk of stroke and transient ischemic attacks. ·
Prophylaxis
of atrial fibrillation among patients with stable coronary artery disease. |
· Hematemesis is
bloody vomiting or material such as coffee grounds, whereas melena is black
stool like tar and has a foul odor. · Sucralfate and
lanzoprazole are given because the patient experiences hematemesis and melena. · The dose of
sucralfate and lanzoprazole given is appropriate. DRP: · Aspirin causes
hematemesis. · Plan: treatment
with ASA 75 mg/day to 100 mg/day for patients with non-ST-segment elevation
myocardial infarction. US guidelines on reducing the gastrointestinal risks
of anti-platelet therapy recommend that ASA doses >81 mg/day should not be
used routinely. DRP: · Simvastatin and
amlodipine: rhabdomyolysis. · Amlodipine
increases levels of simvastatin. Benefit of combination therapy should be
carefully weighed against the potential risks of combination. Potential for
increased risk of myopathy/rhabdomyolysis. · Plan: limit
simvastatin dose to not more than 20 mg/day when use concurrently. · The dose of simvastatin
given is appropriate. |
DAFTAR
PUSTAKA
Kaysin, A. & Viera, J.A., 2016, Community-Acquired
Pneumonia in Adults: Diagnosis and Management, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina.
Inamdar,
A.A. & Inamdar, C.A., 2016, Heart Failure: Diagnosis, Management and Utilization,
Journal of Clinical Medicine, University Medical Center, Hackensack, NJ 07601,
USA.
Lareau,
S. dkk., 2019, Chronic Obstructive Pulmonary Disease (COPD), American
Thoracic Society.
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